Forms → Staff → Benefits → Retiree Benefit Plan Enrollment - FOR NEW RETIREES ONLY
Form number: 455-22R
Audience: MCPS Retirees
Last revised: September 2022
All new retirees must make a selection in each category of MCPS Form 455-22R. If you are a retiree making changes during Open Enrollment or after experiencing a qualifying life event, or you wish to update your beneficiaries, you must use MCPS Form 455-22.
Complete, sign electronically or manually on both sides of this form, and return to the Employee and Retiree Service Center (ERSC). You may fax the signed form to 301-279-3651 or 301-279-3642, or email a PDF of the signed form to ERSC@mcpsmd.org. This form must be signed at the bottom of pages 1 and 2. Please do not mail copies to ERSC once you have faxed or emailed the enrollment form. A confirmation of your requested change(s) will be sent to you. Unsigned forms will be returned to you and become your responsibility to resubmit to ERSC by the appropriate deadline.
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